Provider Demographics
NPI:1215217401
Name:IAOMAI 4 LLC
Entity Type:Organization
Organization Name:IAOMAI 4 LLC
Other - Org Name:LIFEWAY PHARMACY (KOLOA)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAPIT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:808-639-1891
Mailing Address - Street 1:PO BOX 3753
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-6753
Mailing Address - Country:US
Mailing Address - Phone:808-639-1891
Mailing Address - Fax:
Practice Address - Street 1:5330 KOLOA RD STE 2
Practice Address - Street 2:
Practice Address - City:KOLOA
Practice Address - State:HI
Practice Address - Zip Code:96756-8624
Practice Address - Country:US
Practice Address - Phone:808-742-7512
Practice Address - Fax:808-245-7256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
HIPHY8063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131574OtherPK
7468420001Medicare NSC